American Journal of Forensic Medicine and Pathology最新文献

Abstract: Atracurium besylate is a nondepolarizing skeletal muscle relaxant first introduced in 1980. It is used during endotracheal intubation. It causes muscle relaxation during surgery or mechanical ventilation. When people consider suicide, they employ drugs found in their surroundings but not usually injectable muscle relaxants, which are not widely available. Studies on their use in suicide are rarely reported worldwide. This was a case of a 34-year-old male nursing staff, working in the general surgery department's operation theater complex, who was found unconscious in bed in his room in the morning with an empty syringe by the bedside. He was declared dead when brought to the emergency department. Forensic autopsy was conducted, and during the external examination, a needle puncture wound was found over the left cubital fossa. No other external other injuries were observed throughout the body. The toxicological analysis report indicated the presence of laudanosine in the vitreous humor, blood, urine, and skin from the puncture site and underneath vein. Also, the toxicological analysis of the empty syringe found at the crime scene revealed the presence of atracurium, confirming that the victim had administered a lethal dose of atracurium.

Abstract: Despite its severity, anaphylaxis carries a low mortality rate of less than 1%, making the cohort seen in the forensic pathology setting a small and unique subset of the majority of cases of anaphylaxis in the community. Clinically, cardiovascular disease has been recognized as a risk factor for fatal anaphylaxis; however, there is scant forensic pathology research investigating this risk factor, whereas autopsy textbooks emphasize physical respiratory changes seen in the broader clinical cohort. This 20-year retrospective study examined all fatal anaphylactic deaths in the state of Queensland, Australia, to document the underlying disease of the cases, tryptase levels, triggers, and postmortem findings. Our study found that cardiovascular disease was prevalent in 83.3% of cases of fatal anaphylaxis. Although asthma was prevalent in food-related fatal anaphylaxis (60%) in our cohort, it was poorly represented overall (28%), in contrast to clinical research. Additionally, only 43% of cases showed respiratory changes that were greater than mild. Our findings emphasize the difference between the clinical and postmortem anaphylaxis cohorts, and provide autopsy evidence of a potential role of cardiovascular disease in fatal anaphylaxis.

Abstract: The teenage population is highly vulnerable to drug exposure, use, and misuse due to the physical and emotional development that occurs at those ages. Social influences, like the isolation experienced during the COVID-19 pandemic and social media, can exacerbate this vulnerability. To better understand the potential impact of these influences on teenage drug use, postmortem results reported by a large reference laboratory from 2017 to 2021 corresponding to the teenage population were evaluated for various drugs of misuse. These data revealed a marked increase (385%) in reported fentanyl cases and a 13% increase in positivity rate. Methamphetamine- and cocaine-positive cases also increased 126% and 54%, with a net percent positivity of +0.6% and -0.5%, respectively. Conversely, heroin showed a consistent decline in reported cases (67%) and a net decrease of 1.0% in positivity rate. In addition to commonly misused drugs, trends for other substances that are prevalent in social media and therefore may disproportionally impact teens, MDMA/MDA, mitragynine, and diphenhydramine, were also assessed. A discussion of drug-related social media trends is presented to provide additional context for the data and trends reported herein, ultimately creating a framework through which social influences on teenage drug use can be better understood.

Abstract: Conduction system hamartoma is a benign hamartomatous lesion arising from Purkinje and Purkinje-like cells of the heart. We aimed to investigate the cases that we detected during postmortem histopathological examination. The histopathology reports of the cases autopsied between 2012 and 2022 were reviewed retrospectively. The cases were evaluated in terms of histopathological features, demographic data, autopsy findings, causes of death, microbiological results, and accompanying cardiac anomalies. There was a total of 4 cases. The female-to-male ratio was 3/1. The mean age of the cases was 5.8 months. The heart weight was found within the normal range when evaluated according to age and gender. Microscopy revealed sharply demarcated cell groups or layers with histiocyte-like cells with foamy cytoplasm. Congenital heart disease and lung infection were given as causes of death in all cases. The lesion, which was previously called histiocytoid cardiomyopathy and many different names, is known as "conduction system hamartoma" in the latest World Health Organization classification (5th edition). Being aware of this entity that causes fatal arrhythmias and sudden cardiac deaths is important for pathologists. Autopsy findings should be evaluated by taking extra samples from the heart if necessary, especially in suspected cases below 2 years of age.

Abstract: In postmortem forensic investigations, where the bladder is voided or dehydrated prior to autopsy, it is possible to wash the bladder with saline to collect the resulting "bladder wash" and any residual urine for toxicological analysis. Although this method is not yet commonplace or standard, a recent study has demonstrated that bladder wash is an effective alternative specimen in postmortem forensic toxicology. The current study aimed to assess forensic pathologists' opinions on the use of bladder wash samples both before and after reviewing bladder wash toxicological data. An online survey was distributed to forensic pathologists from NAME, and responses were analyzed to identify any shifts in perceptions after data presentation. The findings revealed that most forensic pathologists recognized the benefits of bladder wash collection and analysis as well as its usefulness in determining the cause and manner of death, with noticeable changes in perspective following exposure to supporting data. This study highlights the potential value of standardizing the easy and accessible collection of bladder wash for postmortem toxicological analysis, thereby providing forensic pathologists with invaluable information when other biological specimens are unavailable.

Abstract: Flecainide is among the most prescribed antiarrhythmic medications and is used to effectively treat recurrent arrhythmia and maintain normal sinus rhythm by acting as a sodium channel blocker. However, its potent effects and narrow therapeutic window pose increasing risks of flecainide intoxication and ensuing morbidity and mortality. Here we report an unusual case of suicide by intentional flecainide overdose. This case demonstrates the importance of early recognition and treatment in avoiding the adverse consequences of flecainide intoxication, and it also demonstrates the importance of appropriate use and safe storage of flecainide.

Abstract: Iatrogenic infections of cadaveric bone grafts have led to 2 outbreaks of Mycobacterium tuberculosis (Mtb) infection in the United States that have resulted in multiple fatalities. We report a case of one of the bone graft recipients from the 2023 outbreak. A 57-year-old immunocompromised female with a history of renal failure status post 3 kidney transplants underwent a laminectomy with a cadaveric bone graft due to spinal stenosis. She was later hospitalized with diffuse lymphadenopathy and surgical site purulent ulceration. The workup included positive cultures for Mtb. Despite appropriate therapy, the patient died in the hospital. Autopsy findings included purulent discharge from the surgical site, medullary abscesses of one of the transplanted kidneys, diffuse pinpoint areas of softening in the liver, and lung congestion. Histology of the liver and right lung demonstrated loose granulomas with abundant acid-fast organisms. The kidney abscesses were due to Candida species infection. Overall, findings were consistent with disseminated Mtb infection. Additional investigation found similar infections in recipients of the same bone graft source. We compare the Mtb outbreaks to similar outbreaks, including cases of fungal meningitis due to steroid injections, and discuss our approach and strategy in cases of iatrogenic infection.

Abstract: An epidemic of fentanyl overdose deaths has led to community naloxone use to save lives, and it has been suggested that businesses face legal liability for failing to provide naloxone. This study reviewed Maryland fentanyl-related overdose deaths in 2022. A death was considered preventable by widespread availability and use of naloxone in the following circumstances: a witnessed arrest, a person suffering an overdose found within 30 minutes of last being known alive, a person found unresponsive who showed potential to be resuscitated by emergency medical services, or the person being "found dead" in a public area such that a reasonable opportunity existed for someone else to find the decedent earlier and administer naloxone before death occurred. Of the 2047 overdose deaths in the study, 13.5% were deemed possibly preventable, and 2.7% were found such that a business could have possibly provided naloxone. The preventable overdoses were most commonly found by a "close contact" (family, friend, boy/girlfriend, and room/housemate) in a residence. A targeted effort to educate and supply naloxone to people who use drugs and their close contacts offers the best chance of reducing fentanyl overdose deaths. Mandating all businesses to carry naloxone is not supported by this study.